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Helminth Infection Does Not Reduce Risk for Chronic Inflammatory Disease in a Population-Based Cohort Study

Published:October 07, 2011DOI:https://doi.org/10.1053/j.gastro.2011.09.046

      Background & Aims

      Parasitic helminth infections can suppress symptoms of allergy, type 1 diabetes, arthritis, and inflammatory bowel disease in animal models. We analyzed data from a large, population-based cohort study to determine whether common childhood enterobiasis protects against these diseases.

      Methods

      We collected information on individual prescriptions filled for the drug Mebendazole against Enterobius vermicularis for all children born in Denmark 1995–2008 from the National Register of Medicinal Product Statistics (n = 924,749; age 0–14 years); 132,383 of these children (14%) filled a prescription for Mebendazole, 102,482 of the children (11%) had a household peer who was registered with a filled Mebendazole prescription, and the remaining 689,884 children (75%) comprised the reference group. Children diagnosed with asthma, type 1 diabetes, juvenile arthritis, ulcerative colitis, or Crohn's disease were identified from the National Patient Registry. We used Poisson regression to estimate confounder-adjusted incidence rate ratios for first in- or outpatient hospital diagnosis of chronic inflammatory disease according to history of Mebendazole treatment prescribed to children in the study.

      Results

      Chronic inflammatory disease was diagnosed in 10,352 children during 6.4 million person-years of follow-up. The incidence rate ratios was 1.07 for asthma (95% confidence interval [CI]: 1.00–1.13), 1.05 for type 1 diabetes (95% CI: 0.79–1.12), 1.13 for juvenile arthritis (95% CI: 0.94–1.37), 0.77 for ulcerative colitis (95% CI: 0.41–1.46), and 1.44 for Crohn's disease (95% CI: 0.82–2.53). Results were not modified by number of treatments or age at treatment.

      Conclusions

      Based on a population-based analysis, enterobiasis does not reduce risk for asthma, type 1 diabetes, arthritis, or inflammatory bowel disease.

      Keywords

      Abbreviations used in this paper:

      CI (confidence interval), GP (general practitioner), ICD (International Classification of Diseases), IRR (incidence rate ratios)
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      Materials and Methods

       Study Cohort and Data Sources

      A cohort of 924,749 children born alive in Denmark during the period from January 1, 1995 through December 31, 2008 was established using the Civil Registration System,
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      and subsequently linked with the Register of Medicinal Product Statistics, the Integrated Database for Labor Market Research, and the National Patient Registry. Accurate person linkage between registers is possible because all information in national registers is kept under the unique Danish personal identification number assigned to all Danish residents since April 1, 1968.
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      The Danish Civil Registration System A cohort of eight million persons.
      Since January 1, 1995, the Register of Medicinal Product Statistics has contained monthly updated information on all persons' filled prescriptions for subsidized and nonsubsidized medicinal products that have a marketing authorization in Denmark (www.dkma.dk).
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      The information has a high national coverage because prescribed medicine can be collected/purchased at pharmacies only and all pharmacies have a duty by law to report information to the register. Information on number of dispensed packages of a product, Danish medicinal product code on labels of dispensed packages, and updated international Anatomic-Therapeutic Chemical code associated with the Danish product code, is kept for every filling date linked to the personal identification number recorded on the prescription. The Integrated Database for Labor Market Research contains longitudinal information for the entire Danish population about, eg, total income and number of persons living in each household from 1980 to the present. The National Patient Registry contains information about all nonpsychiatric hospital admissions in Denmark since January 1977.
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      • et al.
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      Outpatient hospital contacts have been included since 1995. Information concerning dates of admission and discharge, hospital department and diagnoses is kept for every hospital contact linked to the patient's personal identification number. Diagnoses are coded according to the 8th revision of the International Classification of Diseases (ICD) since January 1, 1977, and the 10th revision since January 1, 1994. The study was based on existing data and approved by the Danish Data Protection Agency (j.nr. 2008-54-0472) and the Danish Medicine Agency. Because subjects were not contacted during the study, written informed consent was not required.

       Anthelminthic Treatment

      From the Register of Medicinal Product Statistics, we obtained information on all filling dates between 1995 and 2008 for Mebendazole prescriptions (Anatomic-Therapeutic Chemical code PO2CA01, Danish tradename Vermox) issued to persons in Denmark. We considered the date of filling a prescription (ie, purchasing Mebendazole) as the approximate date of use of Mebendazole against enterobiasis.

       Chronic Inflammatory Disease

      Chronic diseases included in previous animal models cited in the introduction section and without rare onset and hospitalization in childhood were selected. For each disease, in- and outpatient cases were identified in the National Patient Registry using ICD-10 codes: asthma (J45, J46), type 1 diabetes (E10), juvenile arthritis (M080, M082, M083, M084, M088, M089), ulcerative colitis (K51), and Crohn's disease (K50). For asthma, diagnoses before the age of 5 years were excluded due to the risk of misclassification of asthma-like symptoms with a different etiology (eg, early childhood infection).

       Potential Confounder Variables

      Variables based on the Civil Registration System included age (0–14 years), sex, calendar period (1995–1999, 2000–2005,2005–2008), birth order (1 [for firstborn], 2, and ≥3), degree of urbanization (<25, 25–349, 350–999, 1000–1999, ≥2000 persons/km2), birth place of parents (one or both born in Denmark, both born abroad), maternal age (≤19, 20–24, 25–29, 30–34, ≥35 years), and number of household peers (1, 2, 3, ≥4 persons). Household peers (eg, parents, parental partner, guardians, siblings, half-siblings, step-siblings) were defined by an algorithm using information on addresses, sibling relations, marital status, sex, and age for all persons alive and living in Denmark since 1995. The variable was designed by Statistics Denmark (www.ds.dk). A variable for average gross annual income for each individual was based on information in the Integrated Database for Labor Market research, and calculated as household income divided by number of adults in the household, scaled with a price index to make the income comparable over the study period, and then grouped into 5 levels of 100,000 Danish kroner (ie, ∼ 10,500 Great Britain pounds or ∼ 21,000 US dollars in 2008), with the highest level being >500,000 Danish kroner. A variable denoting parental chronic inflammatory disease status, ie, the same type of disease in one or both biological parents (yes/no) was based on information in the National Patient Registry. Again, ICD-10, and also ICD-8, codes shown within parentheses were used, and we identified parents with any diagnosis of asthma (493.00–493.02, 493.08–493.09) between the age of 5 and 50 years, type 1 diabetes (249.00–249.09), juvenile arthritis (712.09), ulcerative colitis (563.19, 569.04), or Crohn's disease (563.00–563.02, 563.08–563.09). Finally, the following variables were treated as time-dependent: age, calendar period, degree of urbanization, average gross annual income, and parental chronic inflammatory disease.

       Statistical Analyses

      Each child was followed from birth until first in- or outpatient hospital contact for chronic inflammatory disease, death, emigration, or December 31, 2008, whichever came first. For asthma as single outcome, children were followed from the age of 5 years only. Log-linear Poisson regression models were used to estimate competing incidence rate ratios (IRRs) for chronic inflammatory disease by history of filled Mebendazole prescription. A history of filled Mebendazole prescription was treated as a time-varying variable with the categories “Yes,” “No,” or “Other”: The category “Yes” consisted of children registered with a filled Mebendazole prescription issued in their name, ie, personal registration number. In the category “Other,” we included children who had no Mebendazole prescription but had a household peer who did. In this way, the reference category “No” consisted of the remaining children with no Mebendazole prescription for themselves or for any household peer. Finally, the category “Yes” were further divided according to the 3 time-varying variables related to Mebendazole prescriptions, ie, time since latest prescription, age at first prescription, and number of prior filled prescriptions. We chose the first variable to study effects indicating that intestinal symptoms of enterobiasis and inflammatory bowel disease were interchanged by mistake,
      • Jardine M.
      • Kokai G.K.
      • Dalzell A.M.
      Enterobius vermicularis and colitis in children.
      the second to study effects of immunological maturity, and the third to study effects of heavy/persistent enterobiasis or reinfections.
      IRRs were adjusted for age, sex, and calendar period as well as all variables that were significantly (P < .05) associated with any of the 5 disease outcomes in initial multivariable models, including all potential confounder variables; excluded were maternal age and number of household peers. Maximum likelihood estimation of IRRs and 95% confidence intervals (CIs) was performed using the GENMOD procedure in SAS software, version 9.2 (SAS institute Inc, Cary, NC). To evaluate the effect of the modeling of the variance, 2 alternative approaches were used. The approaches were applied on a 20% random sample of the cohort. In one approach, a sandwich estimator taking into account correlation within families was used to model the variance (SAS procedure GENMOD), and in a second approach we used a random effect model with family as the random effect (SAS procedure NLMIXED). Both approaches produced results similar to the traditional Poisson regression model for the main analysis of each disease outcome (yes vs no). We therefore presented all results based on the traditional Poisson regression model. Two-sided P values were based on likelihood ratio tests and 95% CIs on Wald's statistics.

      Results

      The cohort included 924,749 children, ages 0–14 years, of which 132,383 (14%) were registered with a filled Mebendazole prescription issued in their name. Among children with no filled Mebendazole prescription issued in their name, 102,482 (11%) had a household peer who had a Mebendazole prescription (group denoted “Other” in the tables), and the remaining 689,884 (75%) reference children had no such household peer. Overall, 10,352 children (1.11%, or 162/100,000 per year) developed a chronic inflammatory disease during 6,405,013 person-years of follow-up between 1995 and 2008.
      Table 1 presents the IRR for asthma, type 1 diabetes, and juvenile arthritis by history of filled Mebendazole prescription (ie, use of Mebendazole). Overall, use of Mebendazole (ie, indicating enterobiasis) was associated with a small and significant increase of 5% in the IRR for having any of the 3 diseases (IRR: 1.05; 95% CI: 1.00–1.12) when compared with nonusers. For each disease, there was a small increase of 5%–13% in the respective IRRs, which was significant for asthma (P = .04) and not type 1 diabetes (P = .45) and juvenile arthritis (P = .23). Among the Mebendazole users, neither age at first filled Mebendazole prescription (Pany = .21, P = .70, P = .37, and P = .33), nor prior number of filled Mebendazole prescriptions (Pany = .22, P = .45, P = .41, and P = .54) was associated with the IRR of having any disease, asthma, type 1 diabetes, and juvenile arthritis, respectively (see Table 1).
      Table 1Incidence Rate Ratios for 3 Chronic Inflammatory Diseases According to History of Filled Individual-Level Prescriptions for the First-Choice Drug Mebendazole Against Enterobiasis in a Cohort of All Children Born in Denmark 1995–2008
      Any diseaseAsthma
      Excluding diagnosis of asthma before the age of 5 years.
      Type 1 diabetesJuvenile arthritis
      CasesPYRSIRR (95% CI)
      IRRs and CIs are estimated in a traditional Poisson regression model with adjustment for age, sex, calendar period, birth order, average gross annual income based on total household income, degree of urbanization, birth place of parents, and any parental diagnoses of the specific outcome.
      CasesIRR (95% CI)
      IRRs and CIs are estimated in a traditional Poisson regression model with adjustment for age, sex, calendar period, birth order, average gross annual income based on total household income, degree of urbanization, birth place of parents, and any parental diagnoses of the specific outcome.
      CasesIRR (95% CI)
      IRRs and CIs are estimated in a traditional Poisson regression model with adjustment for age, sex, calendar period, birth order, average gross annual income based on total household income, degree of urbanization, birth place of parents, and any parental diagnoses of the specific outcome.
      CasesIRR (95% CI)
      IRRs and CIs are estimated in a traditional Poisson regression model with adjustment for age, sex, calendar period, birth order, average gross annual income based on total household income, degree of urbanization, birth place of parents, and any parental diagnoses of the specific outcome.
      Filled prescription for Mebendazole
      No718352651 (reference)P = .0753341 (reference)P = .049521 (reference)P = .458971 (reference)P = .23
      Yes
      IRRs did not change materially with different modeling of variance (traditional Poisson regression, p; Poisson regression with variance modeled by a sandwich estimator, s; Poisson regression with a random family effect, r) in a random 20% sample: Any disease: IRRp: 1.16 (0.99–1.35), IRRs: 1.16 (0.99–1.35), IRRr: 1.16 (0.99–1.35); asthma: IRRp: 1.19 (1.00–1.41), IRRs: 1.19 (1.00–1.41), IRRr: 1.19 (1.00–1.41); type 1 diabetes: IRRp: 0.98 (0.58–1.67), IRRs: 0.98 (0.58–1.67), IRRr: 0.99 (0.58–1.67), juvenile arthritis: IRRp: 1.23 (0.73–2.08), IRRs: 1.23 (0.73–2.09), IRRr: 1.23 (0.73–2.09).
      16306091.05 (1.00–1.12)
      The IRR did not change materially: When adjusted for age, sex, and calendar period only: IRR: 1.04 (0.98–1.09), IRRother: 0.97 (0.91–1.03); when stratified by time since latest filled prescription (see also Table 2): P = .40, IRR0–1y: 1.08 (1.00–1.17), IRR2–14y: 1.03 (0.96–1.11); when further adjusting for parental inflammatory bowel disease.
      13491.07 (1.00–1.13)1351.05 (0.79–1.12)1321.13 (0.94–1.37)
       Age (y) at first filled prescription
       0–24552181.06 (0.97–1.17)P = .723621.08 (0.97–1.20)P = .70541.09 (0.83–1.44)P = .37390.93 (0.68–1.29)P = .33
       3–58652981.04 (0.97–1.11)7301.05 (0.97–1.13)700.89 (0.69–1.14)651.21 (0.94–1.58)
       6–8258791.07 (0.94–1.21)2161.08 (0.94–1.24)180.72 (0.45–1.15)241.48 (0.97–2.25)
       9–1452151.22 (0.93–1.61)411.26 (0.92–1.72)71.22 (0.57–2.60)40.95 (0.35–2.58)
       Prior number of filled prescriptions (i.e. prior to the latest)
      Multiple prescriptions were defined as those filled >4 weeks apart and were considered a proxy for heavy/persistent infections or reinfections. Using intervals of >12 weeks did not change the results materially. The recommended treatment duration using Mebendazole tablets or mixture was 5–8 weeks for normal infections (100 mg as single dose for a total of 3 times with 2- to 3-week interval), and 11 weeks for heavy infections (100 mg as single dose for a total of 6 times with 2-week intervals).
       011044331.04 (0.98–1.11)P = .219141.05 (0.98–1.13)P = .45980.90 (0.73–1.11)P = .41921.13 (0.91–1.41)P = .54
       12931061.03 (0.91–1.15)2471.06 (0.93–1.20)260.90 (0.61–1.34)200.98 (0.62–1.53)
       2+233701.18 (1.03–1.34)1881.16 (1.01–1.35)251.22 (0.88–1.82)201.39 (0.88–2.18)
      Other
      Includes children who did not themselves have a Mebendazole prescription but who lived in a household with a person who did (eg, a sibling or parent).
      11975311.00 (0.94–1.06)
      The IRR did not change materially: When adjusted for age, sex, and calendar period only: IRR: 1.04 (0.98–1.09), IRRother: 0.97 (0.91–1.03); when stratified by time since latest filled prescription (see also Table 2): P = .40, IRR0–1y: 1.08 (1.00–1.17), IRR2–14y: 1.03 (0.96–1.11); when further adjusting for parental inflammatory bowel disease.
      9480.98 (0.91–1.05)1351.05 (0.87–1.27)1141.13 (0.93–1.39)
      PYRS, person-years at risk (in thousands).
      a Excluding diagnosis of asthma before the age of 5 years.
      b IRRs and CIs are estimated in a traditional Poisson regression model with adjustment for age, sex, calendar period, birth order, average gross annual income based on total household income, degree of urbanization, birth place of parents, and any parental diagnoses of the specific outcome.
      c IRRs did not change materially with different modeling of variance (traditional Poisson regression, p; Poisson regression with variance modeled by a sandwich estimator, s; Poisson regression with a random family effect, r) in a random 20% sample: Any disease: IRRp: 1.16 (0.99–1.35), IRRs: 1.16 (0.99–1.35), IRRr: 1.16 (0.99–1.35); asthma: IRRp: 1.19 (1.00–1.41), IRRs: 1.19 (1.00–1.41), IRRr: 1.19 (1.00–1.41); type 1 diabetes: IRRp: 0.98 (0.58–1.67), IRRs: 0.98 (0.58–1.67), IRRr: 0.99 (0.58–1.67), juvenile arthritis: IRRp: 1.23 (0.73–2.08), IRRs: 1.23 (0.73–2.09), IRRr: 1.23 (0.73–2.09).
      d The IRR did not change materially: When adjusted for age, sex, and calendar period only: IRR: 1.04 (0.98–1.09), IRRother: 0.97 (0.91–1.03); when stratified by time since latest filled prescription (see also Table 2): P = .40, IRR0–1y: 1.08 (1.00–1.17), IRR2–14y: 1.03 (0.96–1.11); when further adjusting for parental inflammatory bowel disease.
      e Multiple prescriptions were defined as those filled >4 weeks apart and were considered a proxy for heavy/persistent infections or reinfections. Using intervals of >12 weeks did not change the results materially. The recommended treatment duration using Mebendazole tablets or mixture was 5–8 weeks for normal infections (100 mg as single dose for a total of 3 times with 2- to 3-week interval), and 11 weeks for heavy infections (100 mg as single dose for a total of 6 times with 2-week intervals).
      f Includes children who did not themselves have a Mebendazole prescription but who lived in a household with a person who did (eg, a sibling or parent).
      Table 2 presents the IRR for inflammatory bowel disease by history of filled Mebendazole prescription. Overall, there was no significant association between use of Mebendazole and inflammatory bowel disease (IRR: 1.33; 95% CI: 0.97–1.83) when compared with reference children. However, in strata compared with reference children, the IRR was significantly increased for children with 0–1 year (IRR: 1.77; 95% CI: 1.17–2.67) but not 2–14 years (IRR: 1.06; 95% CI: 0.70–1.62) since latest filled Mebendazole prescription. Correspondingly stratified IRRs for the combined outcome in Table 1 was close to unity (IRR0–1y: 1.08; 95% CI: 1.00–1.17, IRR214y: 1.03; 95% CI: 0.96–1.11). The short period of 0–1 year suggested a bias, eg, some general practitioners (GPs) might have misclassified reports of beginning symptoms of ulcerative colitis with enterobiasis (proctitis with pruritus anis) and prescribed Mebendazole. Therefore, further analyses were restricted to users with 2–14 years since latest filled Mebendazole prescription. The results of the analyses, presented in Table 2, show that neither age at first (P = .60), nor prior number of (Pintestinal = .28), filled Mebendazole prescriptions was associated with the IRR for inflammatory bowel disease.
      Table 2Incidence Rate Ratios for Inflammatory Bowel Disease According to History of Filled Individual-Level Prescriptions for the First-Choice Drug Mebendazole Against Enterobiasis in a Cohort of All Children Born in Denmark 1995–2008
      Multiple prescriptions were defined as those redeemed >4 weeks apart and were considered a proxy for heavy/persistent infections or reinfections. See also Table 1.
      Inflammatory bowel disease
      CasesPYRSIRR (95% CI)
      IRRs are estimated and adjusted as indicated in table 1.
      Filled prescription for Mebendazole
      No24552651 (reference)P = .07
      Yes536091.33 (0.97–1.83)
      The IRR did not change materially when adjusting for age, sex, and calendar period only: IRR: 1.34 (0.98–1.83), IRRother: 1.36 (0.97–1.89).
       Time since latest filled prescription (y)
       0–1263081.77 (1.17–2.67)
      Time was categorized in 0–1 and 2–14 years because of similar direction of IRR when using detailed intervals, eg, IRR0y: 1.76, IRR1y: 1.77, IRR2y: 0.20, IRR3y: 1.19, and IRR4y: 0.53 (95% CIs not shown).
      P = .07
      Ulcerative colitis: P = .002, IRR0–1y: 2.39 (1.48–3.87), IRR2–14y: 0.77 (0.41–1.46), IRRother: 1.28 (0.81–2.01). Crohn's disease: P = .37, IRR0–1y: 0.94 (0.41–2.17), IRR2–14y: 1.44 (0.82–2.53), IRRother: 1.45 (0.88–2.40). Because we could not rule out a noncausal association for the strata 0–1 year (GPs could have misclassified beginning symptoms of ulcerative colitis with enterobiasis, eg, proctitis with pruritus anis, and prescribed Mebendazole) further analyses below in the table were restricted to children in the strata 2–14 years.
       2–14273011.06 (0.70–1.62)
        Age (y) at first filled prescription
        0–271200.90 (0.42–1.93)P = .60
        3–5181471.13 (0.70–1.83)
        6–8231
        9–1403
        Prior number of filled prescriptions
      Multiple prescriptions were defined as those redeemed >4 weeks apart and were considered a proxy for heavy/persistent infections or reinfections. See also Table 1.
        0222331.19 (0.76–1.88)P = .28
        13460.71 (0.29–1.75)
        2+222
      Other
      Includes children who did not have a Mebendazole prescription themselves but who lived in a household with a person who did (eg, a sibling or parent).
      445311.36 (0.97–1.90)
      PYRS, person-years at risk (in thousands).
      a IRRs are estimated and adjusted as indicated in table 1.
      b The IRR did not change materially when adjusting for age, sex, and calendar period only: IRR: 1.34 (0.98–1.83), IRRother: 1.36 (0.97–1.89).
      c Time was categorized in 01 and 214 years because of similar direction of IRR when using detailed intervals, eg, IRR0y: 1.76, IRR1y: 1.77, IRR2y: 0.20, IRR3y: 1.19, and IRR4y: 0.53 (95% CIs not shown).
      d Ulcerative colitis: P = .002, IRR0–1y: 2.39 (1.48–3.87), IRR2–14y: 0.77 (0.41–1.46), IRRother: 1.28 (0.81–2.01). Crohn's disease: P = .37, IRR0–1y: 0.94 (0.41–2.17), IRR2–14y: 1.44 (0.82–2.53), IRRother: 1.45 (0.88–2.40). Because we could not rule out a noncausal association for the strata 0–1 year (GPs could have misclassified beginning symptoms of ulcerative colitis with enterobiasis, eg, proctitis with pruritus anis, and prescribed Mebendazole) further analyses below in the table were restricted to children in the strata 2–14 years.
      e Multiple prescriptions were defined as those redeemed >4 weeks apart and were considered a proxy for heavy/persistent infections or reinfections. See also Table 1.
      f Includes children who did not have a Mebendazole prescription themselves but who lived in a household with a person who did (eg, a sibling or parent).
      In one robustness analysis in which outcomes were restricted to cases with 2 hospital contacts for chronic inflammatory disease, there was again no association between a history of a filled Mebendazole prescription and any asthma, type 1 diabetes, and juvenile arthritis: IRR0–1y: 0.99 (95% CI: 0.90–1.10), IRR2–14y: 0.98 (95% CI: 0.90–1.08), IRROther: 1.02 (95% CI: 0.95–1.10), or any inflammatory bowel disease: IRR0–1y: 1.29 (95% CI: 0.65–2.58), IRR2–14y: 1.22 (95% CI: 0.72–2.06), IRROther: 1.27 (95% CI: 0.79–2.05). In another robustness analysis, IRRs were calculated among children with no siblings and again the results were robust for asthma, type 1 diabetes, and juvenile arthritis: IRR0–1y: 1.01 (95% CI: 0.89–1.15), IRR2–14y: 1.17 (95% CI: 0.71–1.91), IRROther: 1.00 (95% CI: 0.94–1.06), as well as for inflammatory bowel disease, although here the number of patients who were prescribed Mebendazole was small: IRR0–1y: 1.04 (95% CI: 0.46–2.37; 6 exposed cases), IRR2–14y (no exposed cases), and IRROther:1.37 (95% CI: 0.98–1.92).

      Discussion

      This nationwide study of Danish children does not support the hypothesis that enterobiasis protects against development of chronic inflammatory disease, even if acquired early in life or several times.
      The study had a strong statistical power that relied on the immense size of our national cohort and does not support the existence of even small protective effects. For example, based on 95% CIs, the highest risk reduction compatible with our data was 0% for asthma, 21% for type 1 diabetes, 6% for juvenile arthritis, and 30% for inflammatory bowel disease. In comparison, a meta-analysis of 33 studies of helminths and asthma found that current infection with hookworm is associated with a 50% reduction in risk of asthma (95% CI: 10%–72%), enterobiasis an insignificant risk reduction of 13% (odds ratio = 0.87, 95% CI: 0.43–1.75),
      • Huang S.L.
      • Tsai P.F.
      • Yeh Y.F.
      Negative association of Enterobius infestation with asthma and rhinitis in primary school children in Taipei.
      • Jarrett E.E.
      • Kerr J.W.
      Threadworms and IgE in allergic asthma.
      • Alshishtawy M.M.
      • Abdella A.M.
      • Gelber L.E.
      • et al.
      Asthma in Tanta, Egypt: serologic analysis of total and specific IgE antibody levels and their relationship to parasite infection.
      • Alcasid M.L.
      • Chiaramonte L.T.
      • Kim H.J.
      • et al.
      Bronchial asthma and intestinal parasites.
      • Carswell F.
      • Merrett J.
      • Merrett T.G.
      • et al.
      IgE, parasites and asthma in Tanzanian children.
      • Carswell F.
      • Meakins R.H.
      • Harland P.S.
      Parasites and asthma in Tanzanian children.
      • Nascimento Silva M.T.
      • Andrade J.
      • Tavares-Neto J.
      [Asthma and ascariasis in children aged two to ten living in a low income suburb].
      • Scrivener S.
      • Yemaneberhan H.
      • Zebenigus M.
      • et al.
      Independent effects of intestinal parasite infection and domestic allergen exposure on risk of wheeze in Ethiopia: a nested case-control study.
      and Ascaris lumbricoides a risk increase of 34% (95% CI: 5%–71%).
      • Leonardi-Bee J.
      • Pritchard D.
      • Britton J.
      Asthma and current intestinal parasite infection: systematic review and meta-analysis.
      The latter risk increase has been attributed to an asthma-like eosinophil pneumonitis, Loeffler syndrome, provoked by ascarid larvae migrating through the lungs.
      • Calvert J.
      • Burney P.
      Ascaris, atopy, and exercise-induced bronchoconstriction in rural and urban South African children.
      • Loeffler W.
      Transient lung infiltrations with blood eosinophilia.
      Another meta-analysis of 21 studies found that current infection with hookworms, A lumbricoides, Trichuris trichiura, or schistosomes was associated with an overall reduction of 38% (95% CI: 24%–40%) for risk of having skin-reactivity to at least one allergen, although not house dust mite and cockroach allergens that typically trigger asthma attacks.
      • Feary J.
      • Britton J.
      • Leonardi-Bee J.
      Atopy and current intestinal parasite infection: a systematic review and meta-analysis.
      The cited meta-analyses could make restricted conclusions about causality because no prospective cohort studies were found in the systematic literature search, only cross-sectional studies and case-control studies, and such studies may be prone to bias. To our knowledge, the present study is the first prospective cohort study addressing a relationship between helminth infection and asthma. In the cited meta-analyses, bias was reduced by focusing on effects of stool-tested current helminth infection, but this restricted the conclusions to concern effects on established asthma and skin-reactivity to allergens. Such effects, however, are not supported by recent clinical trials in which controlled hookworm or pig whipworm (Trichuris suis) infection demonstrated no effectiveness against asthma,
      • Feary J.R.
      • Venn A.J.
      • Mortimer K.
      • et al.
      Experimental hookworm infection: a randomized placebo-controlled trial in asthma.
      skin-reactivity to allergens,
      • Feary J.R.
      • Venn A.J.
      • Mortimer K.
      • et al.
      Experimental hookworm infection: a randomized placebo-controlled trial in asthma.
      • Bager P.
      • Wohlfahrt J.
      • Kristensen B.
      • et al.
      Reply (correspondence).
      or allergic rhinitis.
      • Bager P.
      • Arnved J.
      • Ronborg S.
      • et al.
      Trichuris suis ova therapy for allergic rhinitis: a randomized, double-blind, placebo-controlled clinical trial.
      Considering these inconsistent results, a causal explanation for the protective effects found in the meta-analyses could be that helminth infection suppresses the short priming with allergen rather than the subsequent chronic reactivity to allergen, which progresses clinical disease.
      • Rodrigues L.C.
      • Newcombe P.J.
      • Cunha S.S.
      • et al.
      Early infection with Trichuris trichiura and allergen skin test reactivity in later childhood.
      Other poorly addressed explanations are reverse causation whereby allergic individuals are less likely to establish helminth infections or a bias, eg, from unintended exclusion of infected allergic individuals from some research projects.
      Very few previous studies investigated an association with enterobiasis a priori by using perianal tape test,
      • Huang S.L.
      • Tsai P.F.
      • Yeh Y.F.
      Negative association of Enterobius infestation with asthma and rhinitis in primary school children in Taipei.
      • Jarrett E.E.
      • Kerr J.W.
      Threadworms and IgE in allergic asthma.
      • Bahceciler N.N.
      • Ozdemir C.
      • Kucukosmanoglu E.
      • et al.
      Association between previous enterobiasis and current wheezing: evaluation of 1018 children.
      whereas others
      • Alshishtawy M.M.
      • Abdella A.M.
      • Gelber L.E.
      • et al.
      Asthma in Tanta, Egypt: serologic analysis of total and specific IgE antibody levels and their relationship to parasite infection.
      • Alcasid M.L.
      • Chiaramonte L.T.
      • Kim H.J.
      • et al.
      Bronchial asthma and intestinal parasites.
      • Carswell F.
      • Merrett J.
      • Merrett T.G.
      • et al.
      IgE, parasites and asthma in Tanzanian children.
      • Carswell F.
      • Meakins R.H.
      • Harland P.S.
      Parasites and asthma in Tanzanian children.
      • Nascimento Silva M.T.
      • Andrade J.
      • Tavares-Neto J.
      [Asthma and ascariasis in children aged two to ten living in a low income suburb].
      • Scrivener S.
      • Yemaneberhan H.
      • Zebenigus M.
      • et al.
      Independent effects of intestinal parasite infection and domestic allergen exposure on risk of wheeze in Ethiopia: a nested case-control study.
      • Wordemann M.
      • Diaz R.J.
      • Heredia L.M.
      • et al.
      Association of atopy, asthma, allergic rhinoconjunctivitis, atopic dermatitis and intestinal helminth infections in Cuban children.
      lacked statistical power because they used stool samples and were smaller studies.
      • Leonardi-Bee J.
      • Pritchard D.
      • Britton J.
      Asthma and current intestinal parasite infection: systematic review and meta-analysis.
      • Cook G.C.
      Enterobius vermicularis infection.
      For example, prevalences of enterobiasis among children were 14%–29% using perianal tape test
      • Huang S.L.
      • Tsai P.F.
      • Yeh Y.F.
      Negative association of Enterobius infestation with asthma and rhinitis in primary school children in Taipei.
      • Jarrett E.E.
      • Kerr J.W.
      Threadworms and IgE in allergic asthma.
      • Bahceciler N.N.
      • Ozdemir C.
      • Kucukosmanoglu E.
      • et al.
      Association between previous enterobiasis and current wheezing: evaluation of 1018 children.
      and 0–8% using stool samples.
      • Alcasid M.L.
      • Chiaramonte L.T.
      • Kim H.J.
      • et al.
      Bronchial asthma and intestinal parasites.
      • Carswell F.
      • Merrett J.
      • Merrett T.G.
      • et al.
      IgE, parasites and asthma in Tanzanian children.
      • Carswell F.
      • Meakins R.H.
      • Harland P.S.
      Parasites and asthma in Tanzanian children.
      • Nascimento Silva M.T.
      • Andrade J.
      • Tavares-Neto J.
      [Asthma and ascariasis in children aged two to ten living in a low income suburb].
      • Scrivener S.
      • Yemaneberhan H.
      • Zebenigus M.
      • et al.
      Independent effects of intestinal parasite infection and domestic allergen exposure on risk of wheeze in Ethiopia: a nested case-control study.
      • Wordemann M.
      • Diaz R.J.
      • Heredia L.M.
      • et al.
      Association of atopy, asthma, allergic rhinoconjunctivitis, atopic dermatitis and intestinal helminth infections in Cuban children.
      One a priori study reported an association between current enterobiasis and asthma,
      • Huang S.L.
      • Tsai P.F.
      • Yeh Y.F.
      Negative association of Enterobius infestation with asthma and rhinitis in primary school children in Taipei.
      while the remaining studies reported neither an association with asthma
      • Jarrett E.E.
      • Kerr J.W.
      Threadworms and IgE in allergic asthma.
      • Bahceciler N.N.
      • Ozdemir C.
      • Kucukosmanoglu E.
      • et al.
      Association between previous enterobiasis and current wheezing: evaluation of 1018 children.
      • Alshishtawy M.M.
      • Abdella A.M.
      • Gelber L.E.
      • et al.
      Asthma in Tanta, Egypt: serologic analysis of total and specific IgE antibody levels and their relationship to parasite infection.
      • Alcasid M.L.
      • Chiaramonte L.T.
      • Kim H.J.
      • et al.
      Bronchial asthma and intestinal parasites.
      • Carswell F.
      • Merrett J.
      • Merrett T.G.
      • et al.
      IgE, parasites and asthma in Tanzanian children.
      • Carswell F.
      • Meakins R.H.
      • Harland P.S.
      Parasites and asthma in Tanzanian children.
      • Nascimento Silva M.T.
      • Andrade J.
      • Tavares-Neto J.
      [Asthma and ascariasis in children aged two to ten living in a low income suburb].
      • Scrivener S.
      • Yemaneberhan H.
      • Zebenigus M.
      • et al.
      Independent effects of intestinal parasite infection and domestic allergen exposure on risk of wheeze in Ethiopia: a nested case-control study.
      nor with skin-reactivity to allergens.
      • Bahceciler N.N.
      • Ozdemir C.
      • Kucukosmanoglu E.
      • et al.
      Association between previous enterobiasis and current wheezing: evaluation of 1018 children.
      • Wordemann M.
      • Diaz R.J.
      • Heredia L.M.
      • et al.
      Association of atopy, asthma, allergic rhinoconjunctivitis, atopic dermatitis and intestinal helminth infections in Cuban children.
      The former a priori study used school records and parental questionnaires to recall the result of routine tape test screening among 3107 school children in a Taiwanese city, and reported a 75% (95% CI: 37–90) reduction in risk of parent-reported doctor-diagnosed current asthma, and no association with atopic dermatitis or parental allergy.
      • Huang S.L.
      • Tsai P.F.
      • Yeh Y.F.
      Negative association of Enterobius infestation with asthma and rhinitis in primary school children in Taipei.
      In general, the lack of association with enterobiasis reported in most previous studies
      • Jarrett E.E.
      • Kerr J.W.
      Threadworms and IgE in allergic asthma.
      • Bahceciler N.N.
      • Ozdemir C.
      • Kucukosmanoglu E.
      • et al.
      Association between previous enterobiasis and current wheezing: evaluation of 1018 children.
      • Alshishtawy M.M.
      • Abdella A.M.
      • Gelber L.E.
      • et al.
      Asthma in Tanta, Egypt: serologic analysis of total and specific IgE antibody levels and their relationship to parasite infection.
      • Alcasid M.L.
      • Chiaramonte L.T.
      • Kim H.J.
      • et al.
      Bronchial asthma and intestinal parasites.
      • Carswell F.
      • Merrett J.
      • Merrett T.G.
      • et al.
      IgE, parasites and asthma in Tanzanian children.
      • Carswell F.
      • Meakins R.H.
      • Harland P.S.
      Parasites and asthma in Tanzanian children.
      • Nascimento Silva M.T.
      • Andrade J.
      • Tavares-Neto J.
      [Asthma and ascariasis in children aged two to ten living in a low income suburb].
      • Scrivener S.
      • Yemaneberhan H.
      • Zebenigus M.
      • et al.
      Independent effects of intestinal parasite infection and domestic allergen exposure on risk of wheeze in Ethiopia: a nested case-control study.
      is in agreement with our results for asthma, although lack of statistical power is a more likely explanation for most previous findings. Our large national cohort allowed us to identify a small 7% (0–13%) excess risk of asthma. However, this finding should be interpreted with caution. The small size of the effects in the CIs is difficult to make compatible with a clinically relevant susceptibility toward asthma among children who had enterobiasis, and can easily be due to small biases.
      By using Mebendazole prescriptions as a proxy for enterobiasis, the existence of the Danish drug and patient registries allowed us to test the suggested hypothesis in an entire population and in a prospective follow-up design. The strength of this method derived from the following reasons that enterobiasis and chronic inflammatory disease would unlikely or rarely be misclassified. We used identification of filled prescriptions for Mebendazole in a register that covers the entire Danish population during the last 15 years. By using the filling dates as a proxy for time of enterobiasis, we avoided recall bias. We are confident that most Mebendazole prescriptions are filled because untreated enterobiasis may persist in a family for months despite hygienic precautions, and treatment with Mebendazole is inexpensive and safe. To assess potential misclassifications, we initially considered how well children with or without enterobiasis would be classified when using their Mebendazole prescription as a proxy for enterobiasis. A correct classification of children with enterobiasis is likely determined by 3 factors. First, our experience is that to control spread,
      • Cook G.C.
      Enterobius vermicularis infection.
      • Lohiya G.S.
      • Tan-Figueroa L.
      • Crinella F.M.
      • et al.
      Epidemiology and control of enterobiasis in a developmental center.
      most GPs in Denmark will prescribe Mebendazole based on signs of enterobiasis. Because these signs are quite unique (eg, persistent nocturnal anal pruritus), misclassification would be rare.
      • Hood C.
      Enterobius vermicularis.
      Second, a number of GPs might recommend pyrvinium (Danish tradename Vanquin) instead of Mebendazole, although it discolors with red and less is known about side effects. Because pyrvinium is a nonprescription drug (ie, over-the-counter), the Register of Medicinal Product Statistics receives information about packages purchased at pharmacies and groceries (ie, both have a duty by law to report to the register)–but by product code only, not by person. However, with that information we could total the purchase of pyrvinium and Mebendazole and estimate that only 2% of our reference children used pyrvinium—a fraction unlikely to have biased our study results toward unity. Third, some GPs might prescribe excess Mebendazole packages to one infected child, eg, as a convenient way to provide the household with enough Mebendazole to treat all its members. In this way, however, other infected children in the household would be misclassified. We avoided this potential misclassification by grouping all children who had household peers with a prescription for Mebendazole separately (the group “Other” in the tables). Finally, correct classification of reference children without enterobiasis would depend mainly on 2 factors. First, Mebendazole can be prescribed for other nematodal helminth infections (eg, Ascaris and Trichiura species); however, because such infections are rare in Denmark, the misclassification would be rare.
      • Magnussen P.
      Imported infectious diseases in patients at Blegdam's Hospital and the epidemic diseases department of Rigshospitalet, Copenhagen, during 1975–1986.
      Second, to control spread, some GPs might prescribe Mebendazole to each and every household member, even to siblings who were not infected. However, when restricting our analyses to children without siblings, our results were robust.
      We used as an outcome, national hospital diagnoses with a high validity and completeness for inflammatory bowel disease (90%–97% and 94%), type 1 diabetes (96% and 91%), and juvenile arthritis.
      • Fonager K.
      • Sorensen H.T.
      • Rasmussen S.N.
      • et al.
      Assessment of the diagnoses of Crohn's disease and ulcerative colitis in a Danish hospital information system.
      • Nielsen G.L.
      • Sorensen H.T.
      • Pedersen A.B.
      • et al.
      Analyses of data quality in registries concerning diabetes mellitus—a comparison between a population based hospital discharge and an insulin prescription registry.
      We increased the validity of the asthma diagnoses by restricting diagnoses to ages 5–14 years, but we did not identify all asthmatic children because many have had no hospital contact at this age.
      • Moth G.
      • Vedsted P.
      • Schiotz P.O.
      National registry diagnoses agree with medical records on hospitalized asthmatic children.
      However, we observed that the lack of effect was robust for children who had 2 hospital contacts for chronic inflammatory disease, including asthma. Potential misclassification of chronic inflammatory disease is therefore most likely not to explain our null results.
      A limitation of our study was that we could not outrule some GPs mistakenly prescribed Mebendazole for intestinal symptoms of as yet undiagnosed inflammatory bowel disease. We were inclined to believe in such bias because we observed an excess risk of being diagnosed with ulcerative colitis in the 2 years after latest prescription but not later (see footnote in Table 2, P = .002), and in previous studies using the same national registers, there was excess diagnostic activity (ie, an uncertainty) and prescription of antibiotics in the year before diagnoses of inflammatory bowel disease.
      • Jess T.
      • Simonsen J.
      • Nielsen N.M.
      • et al.
      Enteric Salmonella or Campylobacter infections and the risk of inflammatory bowel disease.
      • Hviid A.
      • Svanstrom H.
      • Frisch M.
      Antibiotic use and inflammatory bowel diseases in childhood.
      The alternative explanation, that enterobiasis somehow trigger ulcerative colitis, would obviously need confirmation in future studies, and is incompatible with the rest of our results, as well as most experiments with helminths and colitis,
      • Elliott D.E.
      • Li J.
      • Blum A.
      • et al.
      Exposure to schistosome eggs protects mice from TNBS-induced colitis.
      • Elliott D.E.
      • Setiawan T.
      • Metwali A.
      • et al.
      Heligmosomoides polygyrus inhibits established colitis in IL-10-deficient mice.
      • Weinstock J.V.
      • Summers R.W.
      • Elliott D.E.
      Role of helminths in regulating mucosal inflammation.
      • Smith P.
      • Mangan N.E.
      • Walsh C.M.
      • et al.
      Infection with a helminth parasite prevents experimental colitis via a macrophage-mediated mechanism.
      • Khan W.I.
      • Blennerhasset P.A.
      • Varghese A.K.
      • et al.
      Intestinal nematode infection ameliorates experimental colitis in mice.
      although not all.
      • Hunter M.M.
      • Wang A.
      • McKay D.M.
      Helminth infection enhances disease in a murine TH2 model of colitis.
      Interestingly, enterobiasis and other helminths that dwell in the intestine have been reported to induce local immune-suppressive T cells and cytokines in inflammatory bowel disease patients, and to reduce disease activity in some cases.
      • Summers R.W.
      • Elliott D.E.
      • Urban Jr, J.F.
      • et al.
      Trichuris suis therapy for active ulcerative colitis: a randomized controlled trial.
      • Summers R.W.
      • Elliott D.E.
      • Urban Jr, J.F.
      • et al.
      Trichuris suis therapy in Crohn's disease.
      • Croese J.
      • O'Neil J.
      • Masson J.
      • et al.
      A proof of concept study establishing Necator americanus in Crohn's patients and reservoir donors.
      • Buening J.
      • Homann N.
      • von Smolinski D.
      • et al.
      Helminths as governors of inflammatory bowel disease.
      • Broadhurst M.J.
      • Leung J.M.
      • Kashyap V.
      • et al.
      IL-22+ CD4+ T cells are associated with therapeutic trichuris trichiura infection in an ulcerative colitis patient.
      In addition, experimental studies have identified a number of immune-suppressive properties of helminth-derived products.
      • Harnett W.
      • Harnett M.M.
      Helminth-derived immunomodulators: can understanding the worm produce the pill?.
      Our population-based observations suggest that enterobiasis can neither be immune-suppressive nor balance early immune maturation in a way that protects against diseases with chronic reactions to otherwise harmless antigens in the intestine, pancreas, joints, or lungs. It might be argued that enterobiasis is a short-term infection of weeks to months, whereas prolonged (years) or repeated helminth infections, as occur in many low-income countries, would be more likely to exert protective effects. However, we found no evidence that repeated enterobiasis protects against the studied chronic inflammatory diseases.
      In contrast to pinworms (enterobiasis), hookworms and schistosomes thrive in tropical regions only. Because increases in the occurrence of chronic inflammatory disease have occurred mainly in nontropical countries, ie, mainly high-income countries, then it is not logical that an absence of tropical helminths is an explanation. The present study was conducted in a high-income country and does not support a common helminth like enterobiasis protecting against chronic inflammatory disease among children. Taken together, we believe one possible explanation could be that absence of helminths has had little impact on the increase in incidence of chronic inflammatory diseases in high-income countries.

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